Emergency Department Flow: What works, what does not work, and how can we improve?

Authors: Franklin I. Lee, MD (EM Resident Physician, Advocate Christ Medical Center) and Kelly Williamson, MD (Attending Physician, Advocate Christ Medical Center) // Edited by: Jennifer Robertson, MD, MSEd and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Why is Emergency Department Flow Important?

Emergency department (ED) overcrowding is a nationwide problem. Overcrowding leads to suboptimal patient care as there are limited resources to handle it. Ironically, in many ways, the burden of overcrowding is partially due to the successful delivery of emergency care. Due to the immense growth of emergency rooms to emergency departments, many patients now see the ED as the best place for initial care of injuries and/or illnesses. In addition, the ED serves a unique role within the community as a safety net. As a safety net, the ED is a place where uninsured patients can receive care, and even a place where patients can receive care and testing when their primary care physicians’ offices are closed or lack the appropriate resources for care delivery. When patient demand exceeds the ability of an ED to function optimally, the consequences are drastic and can include loss of revenue and compromise in the quality of care. The local community may develop feelings of distrust as well.  Approximately 50% of sentinel events causing serious injury or death occur in the emergency department, and according to the Joint Commission, approximately one third of these are related to overcrowding.¹ The risk of death is also higher during times of ED overcrowding. When a patient receives ED care during a period of overcrowding, he or she has a relative risk of in-hospital death of 1.34 within 10 days of admission.² Overcrowding also leads to increased ambulance diversion, which further prolongs the time that a patient can receive potentially life-saving care. In addition, for the hospital, increased wait times increase the number of “left before seen” patients which causes significant revenue loss. A one-hour reduction in ED boarding can lead to approximately nine thousand dollars in additional revenue for the hospital.³

Addressing overcrowding and ED flow should be at the forefront of an ED and institutional agenda. Developing efficient flow through the ED may help mitigate patient morbidity and mortality, improve access to care, decrease medical errors and negligence claims, and improve caregiver job satisfaction. The Institute of Medicine, Agency for Healthcare Research and Quality (AHRQ), and the American College of Emergency Physicians (ACEP) have all emphasized the importance of optimizing ED patient flow.

Successful ED flow should center upon improving efficiency within the ED and throughout the entire hospital. Every hospital system and ED can benefit from administrative improvements and fortunately, the process of improving patient flow remains relatively similar across systems. In 2011, the AHRQ published a document called “Improving Patient Flow and Reducing Emergency Department Crowding, a Guide for Hospitals”. It was designed to help guide changes needed to address crowding concerns across hospital systems.⁴

Forming the Right Team

The first step toward making positive changes in ED flow is choosing the right team to accomplish the task. The makeup of the team largely depends on the scale and scope of the project. An improvement project that will impact several departments within the hospital will need representatives from all of these departments. In addition, the team will need the involvement of senior leadership within the hospital. Larger initiatives may actually benefit from multiple leaders including a team leader, a senior hospital leader, and technical leaders. On the other hand, smaller projects, such as those focused only on ED processes, will likely require a small number of team members. However, in either situation, it is important to understand the necessity of having a champion for the improvement goals. Additionally, in order to strengthen the strategy, it is important to know anyone who would potentially oppose any changes and involve them early in the process.

Choosing a Strategy

There are multiple strategies to approach ED flow. One strategy is the Input-Throughput-Output model.⁵ This model helps breakdown the complexity of ED flow into compartmentalized portions. Input involves the flow of patients into the ED. Input is the most difficult part of the model to predict because it involves a multitude of factors from the community. These factors include access to primary care and access to alternative sites of care. The second part of the model, throughput, refers to the ED processes that impact patient flow, including triage, staffing, and the availability of specialty and diagnostic services. Finally, output refers to the ability of the ED to physically move patients out of department, such as moving patients to inpatient units or discharging them home.

Another strategy that has been gaining popularity is “lean thinking”. This strategy was originally developed from the manufacturing world, more specifically from Toyota Production Systems.⁶ While the details of this process are beyond the scope of this paper, the pillars of this model are important to understand. Lean production aims to reduce waste by designing as simple a process as possible. This is accomplished by constant process improvement, direct employee involvement, and the instilment of a system-wide culture that values continuous improvement.

Challenges

One can expect to encounter many challenges with implementing any flow improvement project. The two most significant challenges are most often staff resistance and lack of staffing resources. These issues can often be alleviated by utilizing staff education and continuous incorporation of staff concerns into post-implementation adjustments. It is also essential to demonstrate a concrete need for action to hospital leadership by performing robust data collection after initial project implementation.

Effective Solutions

ACEP has highlighted several high impact solutions that may help the growing issue of ED overcrowding. These solutions are separated into internal ED actions and hospital-wide actions.⁷ While every ED and hospital has its own nuances, these are improvements that have been shown to have high impact and broad applicability.

ED Process Improvements

Bedside registration can help streamline throughput for almost all ED patients. Rather than going through the long process of triage and registration prior to placement in a bed, bedside registration dramatically cuts time from arrival to bed placement. This process allows earlier initiation of evaluation and treatment, though its success depends upon bed and provider availability. In certain instances, patients can undergo basic preliminary registration at triage, enough to be able to order testing and treatment. They can then complete full registration at the bedside while waiting for test results, completion of treatment, and disposition.

Triage is an area that is critical to ED function, but it can also be a hindrance in other circumstances. Triage can and should be bypassed when beds are available. Patients can be rapidly triaged to critical care areas or fast track areas based on their initial presentations if beds are available. Delaying patients at triage for additional information when beds are available only serves to delay patient care and time to a provider.

Dedicated fast track areas for patients with minor complaints can help to improve the efficiency of the ED by removing low acuity patients from the main flow, which allows additional resources to be focused on higher acuity patients. A dedicated fast track area can also decrease overall throughput time for patients through the department. However, in general, it is important to limit “silos” in the department. A silo, for example, would be a designated area that is unable to be flexible and serve other purposes.

In terms of additional administrative burden, the average emergency physician spends approximately 90-120 minutes in an 8 hour shift on documentation alone.⁸ The use of scribes can significantly improve the time an emergency physician spends on documentation.

Finally, employing a physician in triage can streamline the patient’s overall stay within the ED. While this strategy is often not very popular, its use has been shown to improve efficiency. Physicians have been shown to be effective at making initial assessments of patients based on these limited interactions, and initial physician assessment in triage can help accelerate the discharge of low acuity patients and initiate workup and treatment for higher acuity patients.

Hospital Process Improvements

While addressing ED specific processes can significantly improve throughput, the issue of overcrowding in EDs remains predominantly an output issue. Patients who have a bed request submitted may not be able to immediately move into an inpatient bed due to space constraints on inpatient floors. To fully address the issues of ED flow, output needs to be the forefront of improvement efforts. Specific measures that can help to improve output from ED to inpatient floors are listed below, though it must be noted that hospital wide efforts require significantly more effort and “buy-in” from multiple departments.

Moving hospitals from operating on a normal 9-5 weekday schedule to a 24/7 schedule can help smooth the significant peaks and troughs in bed utilization within the hospital, referred to as “smoothing theory” of improving flow. Hospital resources and staffing drop off significantly at night and on the weekends, which adds increased length of stays for patients and increased inpatient bed utilization. In addition, it has been shown in multiple studies that the larger number of surgical cases early in the week is a significant contributor to ED overcrowding. This large influx of surgical cases early in the week is largely due to the lack of weekend ancillary services such as rehabilitation, social work, case management, and discharge planning. As a result, to have significant impact on patient influxes, a large hospital wide culture change would need to take place. Smoothing the flow of patients can prevent overcrowding, poor handoffs, and avoid delays. For example, Boston Medical Center incorporated this initiative with a noted improvement in ED throughput by 45 minutes and decrease in average wait time from 60 minutes to 40 minutes.⁸

Improving the discharge process can also save valuable hours on an inpatient stay, translating to more available beds when applied hospital-wide. The amount of planning and coordination that goes into a discharge is immense – physicians, nurses, nursing homes, ambulance transport, pharmacy, housekeeping, and ancillary staff are all involved in this process and an in-depth examination of any bottlenecks should be performed. In addition, improved planning and initiation of certain discharge processes early on in the discharge can help to significantly decrease length of stays.

Ineffective Solutions

While there are many solutions that have been shown to be effective to alleviate overcrowding, it must be noted that expanding the physical ED has not yet been shown to be helpful. While this may seem like the easiest option, it often does not solve the primary issue of overcrowding, which is actual patient flow. Adding extra space does not solve the problem if flow cannot be improved. Eventually, without extra providers or inpatient beds, the ED will eventually run into the same issues. As mentioned earlier, it is also inefficient to compartmentalize space within the department into “silos” that are rigid and inflexible. This will only serve to prolong care for some patients. The goal is to make available space within the ED open for use with any type of patient.

Individual Workflow Improvements

In addition to the above listed department-wide or hospital-wide improvement solutions, there are many individual ways for emergency physicians to improve patient flow. For instance, technology can actually be used to improve workflow. Electronic medical records (EMRs) have the ability to improve workflow significantly, but often need to be customized to make full use of their efficiency. Saving personalized order sets, prescription preferences, using “macro templates” can drastically improve provider efficiency. Macro templates essentially can populate a history and physical examination (H&P) with many of the commonly performed review of systems (ROS). Also, the use of templated discharge instructions for various presentations can save time and allow for safe discharges from the ED. All of these efforts can be initiated by providers in order to minimize the amount of time documenting and maximize the amount of time spent with patients.

Anticipating the course of a patient’s stay and considering disposition early on also decreases a patient’s length of stay. Starting the process early for admissions that are clear admits can save valuable hours in throughput. In the same regard, discharging patients when workup is complete should be initiated as early as possible. Performing these tasks early will help with the flow in the department as well as improving cognitive load on the provider.

Summary

ED crowding is an issue that continues to evolve and will impact nearly all emergency physicians. The ED is the location in the hospital that feels the greatest stress from capacity issues hospital-wide. Thus, emergency providers are uniquely positioned to have the greatest impact in flow improvement initiatives. Initiatives can be as small as improvements in our daily workflow to as large as hospital-wide changes that involve multiple specialties. Improving patient flow should be continuously addressed. By improving flow through the ED, we can help our patients by decreasing medical errors, decreasing hospital lengths of stay, and improving our own workplace experience.

References

1. Joint Commission. Sentinel Event Alert, June 17, 2002; http://www.jointcommission.org/sentinelevents/ statistics. Accessed 4 June 2007

2. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213-216.

3. Pines JM, Batt RJ, Hilton JA, Terwiesch C. The financial consequences of lost demand and reducing boarding in hospital emergency departments. Ann Emerg Med; in press.

4. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/ptflow/index.html

5. Solberg LI, Asplin BR, Weinick RM, Magid DJ. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42(6):824-834.

6. Holden RJ. Lean thinking in emergency departments: a critical review. Ann Emerg Med 2010; 57 (3): 265-78.

7. Asplin, Brent, MD, MPH, Frederick C. Blum, MD, Robert I. Broida, MD, Richard Bukata, MD, Hill B. Michael, MD, Stephen R. Hoffenberg, MD, Sandra M. Schneider, MD, Peter Viccellio, MD, and Shari J. Welch, MD. “Emergency Department Crowding: High Impact Solutions.” American College of Emergency Physicians. American College of Emergency Physicians, 25 July 2008. Web. 15 Jan. 2016.

8. Manager, Or. Boston Hospital Sees Big Impact from Smoothing Elective Schedule (n.d.): n. pag. IHIOptimize. OR Manager, Dec. 2004. Web. 15 Jan. 2016.